<?php $class = "registration"; ?>
<?php include 'inc/header.php'; ?>





<div class="row content">
	<div class="container">
    
    
    	<div class="col-md-5 col-md-push-1 centered-text region fadeInLeft slow">
            <img class="bottle-and-tin" src="images/bottle-and-tin.png" width="100%" >
        </div>

    
    	<div class="col-md-5 col-md-push-1 centered-text region fadeInRight slow">
        	<h3>Ingresa tu información</h3>
            <form>
            <div class="row">
            	<div class="col-md-6 input-wrapper">
                	<input type="text" name="fname" class="form-control" placeholder="First Name">
                </div>
                <div class="col-md-6 input-wrapper">
                	<input type="text" name="lname" class="form-control" placeholder="Last Name">
                </div>
            </div>
            <div class="row">
            	<div class="col-md-12 input-wrapper">
                	<input type="text" name="email" class="form-control" placeholder="E-mail">
                </div>
            </div>
            <div class="row">
            	<div class="col-md-12 input-wrapper">
                	<input type="text" name="phone" class="form-control" placeholder="Phone">
                </div>
            </div>
            <div class="row">
            	<div class="col-md-12 input-wrapper">
                	<input type="text" name="address" class="form-control" placeholder="Address">
                </div>
            </div>
            <div class="row">
            	<div class="col-md-12 input-wrapper">
                	<input type="text" name="city" class="form-control" placeholder="City">
                </div>
            </div>
            <div class="row">
            	<div class="col-md-6 input-wrapper">
                	<input type="text" name="state" class="form-control" placeholder="Province/State">
                </div>
                <div class="col-md-6 input-wrapper">
                	<input type="text" name="zipcode" class="form-control" placeholder="Zip Code">
                </div>
            </div>
            <div class="row">
            	<div class="col-md-12 checkbox-wrapper">
            		<label><input type="checkbox">He leído y aceptado los <a href="">Términos y Condiciones</a> de uso.</label>
                	<label><input type="checkbox">Favor de informarme de futuras promociones.</label>
                </div>
            </div>
            <div class="row">
            	<div class="col-md-12 submit-wrapper">
            		<input class="submit-btn gold" type="button" value="Continuar" class="form-control" id="submit-registration" >
                </div>
            </div>
            </form>
           
        </div>
        
      
        
    </div>
</div>


<?php include 'inc/footer.php'; ?>
